1
Data-Driven Clinical Transformation in an Unhealthy Region
Session 140, February 13, 2019
Debra Simmons, COSEHC Executive Director,
Wake Forest University Health Medical Center
2
Debra Simmons, MSN, RN
I have no real or apparent conflicts of interest to report.
Conflict of Interest
3
Who We Are
501c3 Clinical QI Consortium
Established
1993
NHLBI and CDC Recognition
• Data-driven QI Organization
• Network of 30 cardiovascular COEs across the
Southeastern U.S.
4
• Learning Objectives
• The Issue
• The Approach
• Challenges/Barriers
• Case Examples
• Conclusion
• Recommendations
Agenda
5
• Identify challenges and opportunities in transitioning from fee-for-service
to fee-for-value for providers serving high-risk populations
• Illustrate methods used to facilitate transformation in large and
fragmented provider networks, including provider and patient engagement
across large, unhealthy regional populations
• List tools, partnerships and processes used to achieve clinical
transformation
• Describe outcome improvements which have surpassed goals to date:
improving population health, reducing costs and transitioning participating
practices to value-based care models
• Recognize barriers to provider adoption, alignment and active
participation across one of the nation’s largest CMS practice
transformation networks
Learning Objectives
6
Objective:
Transform the health plan network from an episode-driven, physician care delivery
model to a population management-driven, team-based care delivery model
Primary Care Network Redesign at a Major
Health Plan
Cloud-based
population health
management tool
Plan-supported
patient navigation
and coordination
Ongoing clinical
quality
improvement
Standardized
protocols
Primary Care
Redesign
Case Study 1
7
Year One Results
We’ve reinvested all of
our CMFs into hiring 6
new staff members
“
Scaling across our 40 clinics
was impessive... and it hasn’t
disrupted our physicians
“
The Quality Navigator and
I work together to close
gaps in the care puzzle
“
Participating PCPs
440
Attributed members
141,000
Designed, developed, and deployed in
less than 6 months
Fostered practice-health plan
collaboration
Increased PCP appointments by ~30%
In first 10 months, scaled efficiently
to:
8
Outcomes
0% 10% 20% 30% 40% 50% 60% 70%
HYPERTENSION
OPTIMAL CHRONIC KIDNEY CARE
OPTIMAL VASCULAR CARE
OPTIMAL DIABETES CARE
$27 PMPM
net savings
+25%
+40%
+69%
+31%
Improvement in Quality Measure Performance-Major Health Plan
(January ‘14-November ’15)
9
Our Current Work
We are a Center for Medicaid
and Medicare Services' (CMS)
Innovation Center Practice
Transformation Network (PTN)
Serving
4,693 providers,
745 practice sites
4 year
program
Southeastern
U.S. focus
QualityImpact PTN: A Collaboration for
Better Care
10
Supporting Practice Transformation Across a Diverse
Network of Clinicians and Practices in 15 States
Primary
Care
Specialty
Care
Total
PTN YR4
Commitment
Clinicians 2,488 2205 4,693 4,040
Practice Sites 443 302 745 -
Patients 1,262,784 841,856 2,104,640
TOP
SPECIALTIES
Size and
Scale
49
UNIQUE SPECIALTIES
Psychiatry
Cardiology
OBGYN
Surgery
BY CLINICIAN COUNT:
Practice Size
(# of Clinicians)
11
The Issue
Why Healthcare Reform?
12
• Public and Private payer marketplace is dynamic
– The population continues to age and present with more chronic
conditions
– The U.S. continues to expect greater value from its healthcare
“spend”
– The bar continues to rise for attaining Performance goals and value-
based compensation to keep practices surviving and thriving
– Southeast ranked as the region with the highest prevalence of
Cardiovascular Disease
1
(1) https.www.americashealthranking.org/learn/reports/2017-annual-report
The Issue
13
The Issue
14
The Path Toward Accountability
Fee For
Service
Fee For
Service
Pay for
Performance/
Incentives
Pay for
Performance/
Incentives
Episodic
Bundling
Episodic
Bundling
Shared
Savings
Shared
Savings
CapitationCapitation Full RiskFull Risk
The Rising Bar
15
The Goal
• Shift care from emergent to preventive
• Provide care in the most effective and lowest cost setting
• Break the reliance on perverse incentives
• Manage the care of those who need it
• Utilize big data fully
Shift from fee-for-service to Value
16
The Focus
Better
care
Lower
total
medical
costs
More
satisfied
providers
More
satisfied
patients
Proven clinical
quality improvement
leveraging
population health
management
Protect & increase
revenue through
quality-based
incentives, MA
savings, contracts
Team-based
care
empowering
provider to focus
on diagnosis
and treatment
Improved patient
experience,
engagement, and
patient/provider
collaboration
The Quadruple Aim
Making the right thing to do, the easy thing to do.
November/December 2014 Annals of Family Medicine. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider
17
Methods used to Facilitate
Transformation
18
A stepwise, iterative approach:
IMPLEMENT
Drive change at the point of care
by providing hands-on clinical
performance improvement,
implementation expertise, and
tools
Promote innovation by
building practical, scalable
models that address core
transformational objectives
BUILD
Assessment of existing state
and readiness to adopt new
care delivery models
DISCOVER
Approach
More efficient, meaningful, quality-driven care.
19
Key Domains of Value
PATIENT- AND
FAMILY-
CENTERED
CARE DESIGN
CONTINUOUS,
DATA-DRIVEN
QUALITY
IMPROVEMENT
SUSTAINABLE
BUSINESS
OPERATIONS
• Patient and
family
engagement
• Team-based
relationships
• Community
partners
• Evidence-based
care delivery
• Enhanced
access
• Engaged leadership
• Quality
improvement
• Culture
• Transparent
measurement and
monitoring
• Optimal use of HIT
• Strategic use of
practice revenue
• Staff vitality
• Capability to
analyze and
document value
• Operational
efficiency
20
Scale Up ImplementationScale Up Implementation
Communication
Protocols
Communication
Protocols
Standardized
Processes
Standardized
Processes
Education and
Training of Staff
Education and
Training of Staff
HIT
Optimization
HIT
Optimization
Quality TargetsQuality Targets
ASSESSMENT / BUILD
IMPLEMENTATION
RESULTS
Demonstration of OutcomesDemonstration of Outcomes
Collaborative AssessmentCollaborative Assessment
Operational StrategyOperational Strategy
Specialty
Care
Specialty
Care
Transitions of
Care
Transitions of
Care
High-Risk
Complex Care
High-Risk
Complex Care
Care & Team
Management
Care & Team
Management
PilotingPiloting
Select Practice LocationsSelect Practice Locations
Focus on accountable population across care environmentsFocus on accountable population across care environments
Primary
Care
Primary
Care
Care Team ChampionsCare Team Champions
Performance
Improvement
Performance
Improvement
Measurement to
Strategic Goals
Measurement to
Strategic Goals
A Scalable Model
21
Strategies to Overcome
Challenges/Barriers
22
• Participation and Engagement
• Resources
• Variability and Disparity (or lack of EHRs)
Key Challenges/Barriers
23
Participation and Engagement
Primary Contact*
• Communicate program updates
• Act as primary point of contact for the practice
Clinical Champion
• Lead clinical adoption
• Gain buy-in from providers
• Coordinate Protocol
Adoption, Clinical
Education
Operational Champion
• Support workflow
implementation
• Liaise with practice staff
• Assist with prioritization of
operational goals
Technical Champion
• Liaise with HIT Systems
• Lead Population Care
adoption internally
• Re-train/train new Population
Care users post-go live
Key Practice Roles and Responsibilities
24
CULTURE
•Are you ready for
change?
•What obstacles have
you faced gaining
physician buy-in?
•Leadership buy in?
•How are decisions
typically made?
RESOURCES
•What HIT, data and
communication systems
do you have in place?
•What information do
they provide (or not)?
•What have you learned
from them?
STRUCTURE
•What processes do you
already have in place?
•Are they successful?
How are you measuring
their success?
•Must you operate within
an existing structure or
are you looking to start
anew?
Understanding needs and constraints
Resources
25
LeadingFoundational Emerging Advanced
Assessment
Key Success Factors of Value Based Care
Patient and Family Engagement
Team-based Relationships
Enhanced Access
Practice as a Community Partner
Coordinated Care Delivery
PATIENT
AND
FAMILY CENTERED
CARE DESIGN
CONTINUOUS
DATA
DRIVEN QUALITY
IMPROVEMENT
Organized Evidence-based Care
Population Management
Quality Improvement Strategy
Transparent Measurements
SUSTAINABLE
BUSINESS
OPERATIONS
Results Related to Aims
Engaged & Committed Leadership
Optimized HIT
Strategic Use of Practice Revenue
Workforce Vitality and Joy in Work
Capability to Analyze Value
Operational Efficiency
26
Disparate EHR Systems
Integrating Clinical Data across the PTN Network
27
Population Health Management
Utility at the Practice-Level
Pre-visit
Planning
• Identify individual patient
care gaps and enable
targeted care
improvement
• Enhance pre-visit planning
for more activated visits
Population
Health
• Utilize clinical
suites/registries to drive
a campaigned care
delivery approach
• Identify patients for
outreach and
engagement
• Segment and manage
population groups
Clinical Quality
Improvement
• Establish practice goals
to drive quality
improvement
• Align with
QualityImpact support
via best practice
protocols, modules, and
clinical coaching
• Equip providers with a
means to
track/measure quality
28
Focused Population Segmentation
Improving Clinical Care
Asthma
(> 2 years)
Breast Cancer
Screening
(50-74 years)
Chronic Heart
Failure
(> 18 years)
Cervical Cancer
Screening
(21-65 Years)
Chronic Kidney
Disease
(>18 years)
Colorectal Cancer
Screening
(50-75 Years)
COPD
(> 18 Years)
Diabetes
(> 18 Years)
Child & Adolescent
Diabetes
(Less than 18 Years)
Adult Ischemic
Vascular Disease
(> 18 Years)
Adult Hypertension
(18+ Years)
Child & Adolescent
Hypertension
(<18 Years)
Child & Adolescent
Preventative
Services
(2-17 Years)
Child
Immunizations (0-2
Years)
Child & Adolescent
Obesity
(2 - 17 years)
Tobacco Usage &
Exposure
(All Ages)
29
Case Examples
Large Integrated Network-High Risk Region
Independent Rural Practice
Academic Center Physician Practice Group
30
Case 2
• Located in Louisiana
• 46
th
to 50
th
in higher healthcare
costs and lower quality
outcomes
• Multi-specialty practice
• Primary provider in the
Community
• Focus on fee for Service
• Over 400 providers
• Low performer
31
Population Health Management
31
Identifying Patient Care Needs
Narrow down to a specific measure
Selecting a list of patients who do
not meet the measure
Review measures that are due
within the next 60 days
Targeting patients that are outdated
on visits
Clinical Performance of Providers
32
Using actionable data to close patient gaps in care
Seamlessly
integrates
clinical, claims,
and practice
management
data
Highlights
actionable
opportunities to
improve patient
care
33
Established Internal CQI Process
Use of Trending Reports
4/2014-Best Protocol
in 1 Practice
1/2016-”We agreed on a
plan and a
Protocol”
N-656
34
Clinical Improvement Outcomes
Optimal Hypertension Control
78%
Key Strategies
Access to Data
Data Transparency
Network Goals
Systemized Protocol
Payor Contract Negotiations
35
Primary Care and OB/Gyn
Case 3
Implemented Medication Management and Obesity Management Programs incorporating elements of:
• Population Management (risk stratification, identification of care gaps)
• Patient & Family Engagement (collaboration with patients and families using shared care plans,
use of tools to assist patients in assessing need for self management support, staff training on self-
management goal setting)
• Organized, Evidenced-Based Care (regular communication and coordination between primary
care and behavioral health providers, co-location of behavioral health services)
• Transparent Measurement & Monitoring (transparent use of data by defining measures,
monitoring them and sharing metrics with staff)
Implemented Medication Management and Obesity Management Programs incorporating elements of:
• Population Management (risk stratification, identification of care gaps)
• Patient & Family Engagement (collaboration with patients and families using shared care plans,
use of tools to assist patients in assessing need for self management support, staff training on self-
management goal setting)
• Organized, Evidenced-Based Care (regular communication and coordination between primary
care and behavioral health providers, co-location of behavioral health services)
• Transparent Measurement & Monitoring (transparent use of data by defining measures,
monitoring them and sharing metrics with staff)
35
PTN-Practice Collaboration
36
Risk Stratification
• Utilize data to generate chronic
disease-specific patient lists
for outreach
• Gap Analysis-Review out of
compliance measures
Identifying High
Risk
• Identify and manage highest
risk patients, filtered by
disease burden and care
opportunities
37
Patient and Caregiver Engagement
Patient & Caregiver Initiatives
P a t i e n t & C a r e g i v e r
E n g a g e m e n t
1. Health Literacy, social
determinants
integration
2. Readiness to change
and health confidence
patient engagement
tools
3. Tailored approach &
community
partnerships based on
identified barriers
1. Health Literacy, social
determinants
integration
2. Readiness to change
and health confidence
patient engagement
tools
3. Tailored approach &
community
partnerships based on
identified barriers
11
8
7
6
5
3
0
2
4
6
8
10
12
38
Transparency of Data
Sharing with Team
3
8
Performance Spotlight
Improved BP Control
(<140/80) for Chronic
Heart Failure patients by
38 percentage points
Improved HbA1c <8%
for high-risk patients
(>65 yrs) by 20
percentage points
Improved BP Control
(<140/90) for Ischemic
Vascular Disease by 18
percentage points
31
69
44
64
64
82
0
10
20
30
40
50
60
70
80
90
Blood Pressure <
140/80, CHF
HbA1C < 8 (Age >= 65),
Diabetes
Clinical Control Rates, %
May 2017 – July 2018
39
• Metro-Tampa academic medical center and multispecialty CIN
with 585 physicians seeing 483,974 outpatient visits/year
• Deployed a PHM provider for analytics to maximize Medicare Part
B reimbursement and bonus payments
• 14 registry-based quality measures calculated at the group and
individual levels across 30+ medical specialties
Case 4
40
Integrated Outreach Campaign
PHM provider helped close, not just expose, care gaps
In December 2017 an email flu shot campaign was deployed:
• 1st wave of emails sent to 61,000 patients without documentation
of flu vaccination in past 12 months
• 2nd wave of emails sent to non-respondents
• 7.4% responded affirmatively with date and location of their flu
shot
• 50.4% increase in # of patients with documented influenza
vaccination within past 12 months
• MIPS measure performance improved from 13.2% (CMS Decile
3) to 40% (CMS Decile 7) for an overall increase of 203%
Outreach Campaign
41
Initial 6 Months Performance Optimization
Showing percentage improvement in performance rates from data
optimization efforts:
• 203% Improvement in Influenza Vaccination
• 114% Improvement in Diabetic Attention for Nephropathy
• 80% Improvement in IVD: Use of Aspirin/Antiplatelet
• 44% Improvement in Controlling High Blood Pressure
• 23% Improvement in Breast Cancer Screening
• 11% Improvement in Tobacco Use Screening & Cessation
Results
42
Key Improvements
43
Achievements and
Challenges
44
Performance At-a-Glance
Improved high-impact measures in
98,529 of 73,465 total committed patients
with CV-related conditions
Reduced 7,012 unnecessary low back
pain imaging cases.
6,988 avoided all-cause hospital
admissions and ED Visits out of
commitment of 10,040.
Achieved 77% of cost savings
commitment of $59.5 million
Exceeded enrollment commitment by
116% with 4,693 clinicians vs. 4,040
commitment.
116%
Engage
Clinicians
Improve Health
Outcomes
Reduce Unnecessary
Utilization
Generate Cost
Savings
Reduce Unnecessary
Testing & Procedures
69%
P R O G R E S S T O W A R D T A R G E T
G O A L
P R O G R E S S T O W A R D T A R G E T
G O A L
134%
77%
52%
Graduated 36% of practices to APMs
representing 258 practice sites
Transition Practices to
APMs
36%
45
Key Success Strategies
C L I N I C A L
M A N A G E M E N T
C L I N I C A L
M A N A G E M E N T
T R A N S F O R M A T I O N
P R O G R E S S
A P M
R E A D I N E S S
1. Drive Empanelment
2. Align with Payer Value
Programs
3. Guide development of
Post-Acute Networks
4. Integrate AWV, TCM &
CCM
5. Optimize Billing &
Coding
6. Ensure Business
Acumen
7. Facilitate APM
Readiness
Consultations
1. Enhance workflow
design, process
efficiencies, and
appropriate utilization
2. Apply Guidelines &
Expert Coaching
3. Guide development of
Care Management
programs
4. Implement Behavioral
Health Support
strategies and networks
5. Implement Pain
Management and
Opioid Use Strategies
1. Establish Quality
Improvement Process
2. Enable Data Transparency
3. Actionable Data Driven
Improvement Plans
4. Share Provider Reports and
Clinician Compare
5. Review Quarterly
Performance Dashboard
6. Clinical Performance CME
Program (Rapid Cycle
Improvement)
7. Trend Patient-level Data
46
Patient
Improvements
HTN-76,189
HbA1c-5,666
Assertion 1
Achieving Performance Improvement
60%
65%
60%
69%
72%
65%
BP < 140 MMHG DIABETES BP < 140/90
MMHG
A1C < 8 %
Pre and Post Changes in
Control Rates
Baseline Endline
January 2018-December 2018
47
Cost Savings
Cost Savings to Commercial Payers
$3,285,524
$37,710,599
$43,414,858
$59,590,172
June 2017
December
2017
April 2018
4-Year
Commitment
48
QUALITYIMPACT PTN 2017 MEMBER SURVEY RESULTS
Assertion 2:
The evidence base for practice transformation and performance
improvement is credible and valuable
Perceived value of specific areas of QualityImpact PTN support
to practices to date
(1=Not at all valuable, 5=Extremely valuable)
0
1
2
3
4
5
49
#8 – PANEL ASSIGNMENTS
31% Need Improvement
Practice has assigned all patients to a
provider panel and confirmed the
assignments with providers and
patients. Practice reviews and updates
panel assignments on a regular basis.
#10 – CARE MANAGEMENT
36% Need Improvement
Practice has assigned accountability for
care management and is piloting a
process for standardizing care
management for patients determined to
be at highest risk of hospitalizations
and/or complications.
#15 – BEHAVIORIAL HEALTH
33% Need Improvement
Practice is able to consistently
provide access to behavioral
health providers but information
may not always be shared in a
timely or consistent fashion and
coordination with the primary care
team is likewise inconsistent.
#21– PROVIDER REPORTS
50% Need Improvement
Practice regularly produces
reports on how providers and/or
care teams are performing and
meeting quality goals,
transparently shares them within
the organization, and has an
effective system for follow up.
The practice is beginning to
incorporate regular improvement
methodology to execute change
ideas in the practice setting but
the methodology has not yet
been implemented in all areas of
the practice.
#19– QI METHODOLOGY
36% Need Improvement
Challenge: Milestone Gaps
50
Practices &
physicians/NPs opt
in & identify
champions
Data sources
identified
CAP lead &
physicians/NPs receive &
review baseline report
Champion & lead
physician develop
action plan with
QualityImpact
All physicians/NPs sign
off on action plan &
implement interventions
with team
Bi-monthly clinical
data review with
QualityImpact
Apply changes to action plan
as needed based on learnings
Final program impact
evaluation
Customized Performance Improvement
5 CME
credits
5 CME
credits
10
CME
credits
51
Promoting Transparency: Review and
Action Reports
52
Primary Care
Huntsville, Alabama
Family Medicine
6 clinicians
Assertion 3
Bringing forward exemplary practices that demonstrate transformed delivery systems and
exceptional, high “value” performance
• Patient-centric redesign of
provider office to improve
efficiency, workflow and patient
access
• High-risk care management
• Transitional Care
• Data Transparency
• Improved Clinical Performance
Exemplary Practice
Graduated to an MSSP at
Phase 4
Clinical Improvement
62% 80% BP control for HTN (ages 60-85)
69% 78% BP control for HTN (ages 18-59)
65% 75% A1c control for DM (A1c < 8%)
Utilization
ED visit high performer with actual cost of 4.50/1000 vs.
$ 224.00/1000 expected
Radiology Services high performer with actual costs at 81%
of expected ($1,059.63 actual vs. $1,306.23 expected)
Cost
Total Cost of Care high performer with PMPM actual cost of
$231.35 vs. $277.90 expected
53
PATIENT AND FAMILY
ENGAGEMENT
• Integration of the use of the patient portal to schedule appointments, provide
educational resources and collect patient feedback to improve the practice workflow
• Adopted shared decision making, health literacy, social determinants, and disease
education tools
Core Interventions & Strategies to Enable High
Performance
MEDICAL
NEIGHBORHOOD
• Formal agreements with referral providers to define expectations and enhance access for
patients
• Identified local community resources
HIT OPTIMIZATION
• EMR alerts for health maintenance, and overdue labs
• Generated reports and a process for regularly reviewing quality reports
STAFF
ACCOUNTABILITY
• Pre-visit planning, morning huddles
• Defined team member responsibilities during a patient’s visit (e.g., managing EMR alerts,
placing standing orders) and provided quality improvement training to staff
• Implementation of a process to identify and manage high-risk patients
• Focused care coordination-outreach to Patients with high utilization
HIGH-RISK
MANAGEMENT
• Practice consensus on use of evidence-based clinical protocols and standing order sets
EVIDENCE-BASED
GUIDELINES
INTERVENTIONS
STRATEGY DRIVERS
54
Recommendations
55
Structural Components Considerations
Actionable patient
care gap analysis
and registry
functionality
Cloud-Based
Population Health
Analytic Tool
Quality
performance-based
structure
Quality-Based
Financial Incentives
Workflow
optimization and
team-based care
enablement
Practice Facilitation
Process
improvement
education, targeted
clinical guidance
and learning
collaboratives
Education &
Clinical
Training
Process tools and
educational
resources for
patients
Tools &
Resources
56
• Phased Approach to Implementing Change
• Recognize Current vs. Proposed
• User-friendly transparent robust data presented in real-time
• Making data actionable-internal reviews, provider compare
reports, measurement, and trending.
• Engagement of healthcare team-clinical, operational and
technology champions
• Learning and Alignment Training
• Use of CQI and incentives to instill new culture
Recommendations
